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''93|09333'4'! (x]J04'4|B0B4G0G'4G'4,-h3-TI.3,,,BB3
,,,B|0|0|0|0B60 Cutter Mill Road ( Suite 414
Great Neck, NY 11021
516-466-4200 (  HYPERLINK "http://www.butwin.com" www.butwin.com

fax  516-466-4213   no cover page needed


or exit, save and e-mail to allstate@butwin.com

WORKERS COMPENSATION
and DBL
 APPLICATION
       Press TAB to move between fields

Applicants Name: FORMTEXT      DBA : FORMTEXT      Address: FORMTEXT      Agent FORMTEXT       FORMTEXT City, State, Zip: FORMTEXT      Contact FORMTEXT       FORMTEXT County: FORMTEXT       FORMTEXT  FORMTEXT E-mail FORMTEXT       FORMTEXT  FORMTEXT Township: (State of PA only) FORMTEXT       FORMTEXT  FORMTEXT Phone FORMTEXT       FORMTEXT  FORMTEXT Contact & Phone: FORMTEXT       FORMTEXT  FORMTEXT Fax FORMTEXT       FORMTEXT  FORMTEXT E-mail & Website: FORMTEXT       FORMTEXT  FORMTEXT  FORMTEXT  FORMTEXT  FORMCHECKBOX  Individual         FORMCHECKBOX  Partnership         FORMCHECKBOX  Corporation         FORMCHECKBOX  Other:  FORMTEXT      Entity is in business for: FORMTEXT      Years or    FORMCHECKBOX  NewCoverage Effective Date: FORMTEXT       FORMTEXT Entity have prior Workers Comp Ins: FORMCHECKBOX Yes   FORMCHECKBOX  FORMCHECKBOX  No %  If yes,  FORMCHECKBOX  FORMCHECKBOX 1yr    FORMCHECKBOX 2yrs    FORMCHECKBOX 3yrs % Any lapses during that time:   FORMCHECKBOX Yes   FORMCHECKBOX No      %  If yes, list most recent Insurance Carrier:  FORMTEXT  FORMTEXT      General Liability being Quoted / Written through BUTWIN FORMCHECKBOX Yes   FORMCHECKBOX  FORMCHECKBOX No %  If no, why not: FORMTEXT      Describe all operations:   Type here&  FORMTEXT  FORMTEXT      
      FORMCHECKBOX  Office         FORMCHECKBOX  Retail          FORMCHECKBOX  Service          FORMCHECKBOX  Wholesale          FORMCHECKBOX  Manufacturing          FORMCHECKBOX  Other      FORMCHECKBOX  Contractor  %  If the Liability is placed with UticBCDEhijxyz{		scSsK6OJQJ]5B*CJ OJQJ\]ph5B*CJOJQJ\]phB*CJ OJQJ]phj5CJU5B*CJOJQJphff356OJQJaJ
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a First Ins Co, no contractor s Workers Comp is available via BUTWIN
Fed Tax ID #: FORMTEXT       FORMTEXT  FORMTEXT Unemployment Registration #: FORMTEXT       FORMTEXT  FORMTEXT 
# of Full Time Employees (excluding owners): FORMTEXT      # OF Owners: FORMTEXT      # of Part Time Employees: FORMTEXT      Owners Annual Payroll or Draw:$  FORMTEXT       FORMTEXT total # of males: FORMTEXT      Annual Payroll (excluding owners):$  FORMTEXT      total # of females: FORMTEXT      Gross Receipts:$  FORMTEXT      Entity Currently has Workers Comp Insurance: FORMCHECKBOX  Yes      FORMCHECKBOX  No in-force coverage% If yes, Current Declarations & Payroll / Rate pages must be submitted with this application% If NO in-force COVERAGE   % List Payroll Breakdown, by Class FORMTEXT      

 FORMTEXT      

POLICY HISTORY & LOSS INFORMATIONHas your insurance been cancelled or non-renewed in the past three years: FORMCHECKBOX  FORMCHECKBOX Yes    FORMCHECKBOX No % If yes, explain: FORMTEXT      Has the insured had any claims in the last 3 years: FORMCHECKBOX Yes    FORMCHECKBOX No
Previous CarriersPremium# ofClaimClaim DescriptionClaim DateClaimsAmount FORMTEXT      $  FORMTEXT       FORMTEXT      $  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      $  FORMTEXT       FORMTEXT      $  FORMTEXT       FORMTEXT       FORMTEXT      
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